CH 10 Nursing Assessment of the Newborn

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CH 10- Nursing Assessmentof the Newborn

• 1st assessment takes place immediately after
  birth, apgar scores
• Use gloves until after first bath
• Measurements length and weight
• Measurements of head chest
• Wt-average 7 lbs. 8 oz
• Dry keep warm in radiant warmer or mothers arms

2
General Appearance

• Posture and spontaneous movements
• best observed while infant is at rest
• flexed vs limp posture which can signal
  prematurity
• Extension of the neck with an arched back may
  signal CNS problems

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General Appearance

• Noticeable jerky or jittery movements may signal
  CNS problem or metabolic problem such as
  hypoglycemia, hypocalcemia, hypoxia, or drug
  withdrawal
• Repetitive blinking or pedaling movements may
  mean seizure activity
• Prolonged or excessive tremors may signal
  hypoglycemia blood glucose via heelstick should
  be at least 40mg/dl
• Cry should not be high pitched or shrill, may
  indicate neurological disorder or drug withdrawal

4
VITAL SIGNS

• Heart rate, apical for I full minute
• Rate 110-160
• RespirationsIrregular, count 1 full min.
• Rate 30-60periodic breathing normal
• Report nasal flaring, grunting, retractions,
  cessation of resp gt 15 secs
• Fast focus 10-1
• Temperature initial may be rectal, then
  axillary gt 97.7F
• BP 60-80/40-50 mmHg taken with an automatic
  BP cuff

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PHYSICAL CHARACTERISTICS

• SKINtable 10-1
• Meconium stain on skin, nails, cord
• Peeling or cracking postterm infants
• Milia
• Vernix caseosa
• Lanugo
• Acrocyanosis
• Mongolian spots

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HEAD

• Circumference or gt by 1 than chest
• Molding caput succedaneum localized swelling
  of the tissues of the scalp, normal fig 10-4
• Cephalhematoma collection of blood between the
  periosteum a bone of the skull that it covers
  does not cross suture line fig 10-5
• Fontanelles or soft spots if bulging may mean
  increased intracranial pressure if sunken may be
  a late sign of dehydration

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Physical characteristics

• FACEmovements should be symmetrical. Prolonged
  labor, forceps can cause facial paralysis
• EYEScolor established at 3-6 months, infant can
  see best _at_ 8 12 inches.
• Encourage mother to have eye contact or en face
• NOSE infant is nose breather - check patency
  hold 1 nare shut, flaring of nostrils sign of
  distress

8
Physical characteristics

• MOUTH check for palate closure, teeth,
  infection, excessive saliva
• Epsteins pearls normal
• Protruding tongue-sign of Downs syndrome
• Thrush may be picked up during vaginal delivery
  if mom has fungal infection
• EARSmaternal infections, congenital defects, and
  cocaine can cause poor hearing. Screening for
  hearing is done prior to discharge fig 10-7
• Low set ears may be Downs Syndrome fig 10-8

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Physical characteristics

• NECKshort, poor muscle tone, head lags. Teach
  parents to support head
• Asymmetry of the clavicles may mean fracture
• CHESTmeasure at nipple line, 12-13
• Should be 1 less than head
• Witchs milk 1st few weeks
• Breath sounds should be clear

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Physical characteristics

• ABDOMENmoves with chest during respirations
• Umbilical cord2 arteries, 1vein
• Clamped after birth sloughs off at 79 days
• Normal bowel sounds heard after 15 mins or up to
  2 hours after birth
• BLADDERdocument 1st voiding which may be dark
  amber, report foul odor

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Physical characteristics

• GENITALS
• Female white, milky or pink vaginal discharge
  common
• Malenote location of the urinary opening
  -hypospadias, epispadias, phimosis
• Circumcision done for religious reasons or to
  prevent infection
• Testes usually descended

12
Physical characteristics

• ANUSRectal temp done initially to assess if anus
  open. Charting and reporting of 1st stool
  important. Obstruction considered if no stool in
  24 hours.
• BACK inspect for dimples, masses, hair tufts,
  spinal curvatures. Exam hips for dislocation
  fig 10-10

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• EXTREMITIESpolydactyly, syndactyly
• NEUROLOGIC ASSESSMENT important to obtain
  baseline information
• GESTATIONAL AGEBallard scoring system determines
  preterm, posterm done within first 24 hours ch
  16 pg 255
• SGA lt10tile, LGA gt90 tile

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Behavior assessment

• Knowledge about phases promote parent-infant
  attachment and feeding
• 1st period of reactivity quiet state of
  alertness, facilitates bonding
• Phase of active alertness strong sucking reflex
  and hunger, facilitates feeding, lasts about 30
  minutes
• Sleep phase, infant is unresponsive for 2-4 hours
• 2nd period of reactivity, lasts 4-6 hours, feed
  if not done in 1st period

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REFLEXES/SENSES

• REVIEW REFLEXES TABLE 10-2, fig 10-11 10-12
• MORO, PALMAR GRASP,
• PLANTAR REFLEX, BABINSKI,
• TONIC NECK, STEPPING,
• ROOTING